BOP Equipment Failure reporting Form

WELL IDENTIFICATION

*Lease No.:

*Well No.:

API Well No.:

RIG OWNER INFORMATION

*Rig Owner / Drilling Contractor:

*Rig Name:

* Operator:

*Operator Contact Email:

EQUIPMENT DATA

*Subsea / Surface BOP:

*System Integrator (OEM):

*Subunit:

*Item:

*Component:

*Component Manufacturer:

Observed Failure:

*Model:

*Size:

*Pressure Rating:

psi

*OEM Part Number:

OEM Serial Number:

EVENT DATA

Site Specific Information:

Rig Operation at the time of event:

*Location (Region):

*Location (Country):

*Water Depth:

Feet

Control Fluid (Manufacturer / Model):

/

Concentration:

%

Glycol:

%

Was the last sample acceptable?:

Date of last sample:

Event

*Incident Date:

*Where did the failure occur?:

*Description of Event:

*Did the event cause a BOP Stack pull?

HSE Incident:

Other/Comment:

Note - Fields mark with "*" are mandatory.

#REF!

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